Overall Score
CMS Five-Star Quality RatingAverageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasAbove only 45% of peers1,167 rated homes · average 2.8★
- Harris CountyAbove only 45% of peers94 rated homes · average 2.8★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs TX avg
- StaffingCan add or remove a star2★−0.1 vs TX avg
- Quality measuresCan add or remove a star5★+1.2 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
Why it matters
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 37% of peersTX avg2.1★U.S. avg2.9★
What is staffing rating?
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
Why it matters
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 68% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
Why it matters
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff2.75hrsAbove only 6% of peersTX avg3.40Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.32hrsAbove only 33% of peersTX avg0.44Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better46%Above 62% of peersTX avg51%RN turnover20%
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$12,893Above 59% of peersTX avg$55,368Fines · denials1 · 0
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles29citations
5inspection dates
0actual harm (G–I)
5immediate jeopardy (J–L)
Mar 6, 2025most recent
Citations by monthOct 2022 – Mar 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Mar 6, 2025Cycle 1worst E · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 10, 2025
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Mar 10, 2025
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Mar 10, 2025
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Mar 10, 2025
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Mar 10, 2025
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and DietaryD · isolatedCorrected Mar 10, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Mar 10, 2025
Apr 23, 2024Cycle 2worst J · immediate jeopardy
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareJ · isolatedCorrected Jun 10, 2024
- F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Resident Assessment and Care PlanningJ · isolatedCorrected May 10, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesJ · isolatedCorrected May 10, 2024
Dec 13, 2023Cycle 2worst F · no actual harm
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalD · isolatedCorrected Dec 28, 2023
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 28, 2023
- Conduct mandatory training, for all staff, on the facilityâs Quality Assurance and Performance Improvement Program.AdministrationE · patternCorrected Dec 28, 2023
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationD · isolatedCorrected Dec 28, 2023
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationD · isolatedCorrected Dec 28, 2023
- F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsD · isolatedCorrected Dec 28, 2023
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationD · isolatedCorrected Dec 28, 2023
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Dec 28, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Dec 28, 2023
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryD · isolatedCorrected Dec 28, 2023
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationF · widespreadCorrected Dec 28, 2023
Sep 25, 2023Cycle 3worst J · immediate jeopardy$12,893
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningJ · isolatedCorrected Oct 12, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Oct 12, 2023
Oct 5, 2022Cycle 3worst E · no actual harm
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Nov 4, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Nov 4, 2022
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Nov 4, 2022
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected Nov 4, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Nov 4, 2022
- F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Nov 4, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined2.75hrs
- Registered nursesRN hours only0.32hrs
- Licensed practical nursesLPN hours0.74hrs
- Nurse aidesCNA hours1.69hrs
- Weekend nursingAll staff on Saturdays and Sundays2.45hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better46%Above 62% of peersTX avg 51%
- RN turnoverRegistered nurses only20%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy120 certified beds · ~70 residents a day59%Above only 31% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $12,893In fines
- 1Fine
- 0Payment denials
- $55,368TX avg in fines
Above 59% of peersFewer fines than 59% of rated homes in Texas
Actions on record
- Sep 25, 2023Civil money penalty$12,893
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Focused Post Acute Care Partners25 facilities in the chain2.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Operational or managerial control
- Shawn Conley
- Chambers County Public Hospital District No. 1
- Focused Post Acute Care Partners LLC
- Focused Post Acute Care Partners Management, LLC
- Fpacp Burnet LLC
- Mark McKenzie
- Elizabeth Newton
- Loretta Strubbe
- +1 more
Direct owners (5%+)
- Chambers County Public Hospital District No. 1
Corporate officers
- Kimberly Cooper
- Elizabeth Newton
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 675849 · 3921 N MAIN, BAYTOWN, TX, 77521.
- Percentiles compare this facility with every rated nursing home in Texas and Harris County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
